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For the healthcare community, the Institute of Medicine's (IOM's) Crossing the Quality Chasm report 1 was a wake-up call. Among the messages it conveyed was that healthcare could improve if provider groups surrender sometimes myopic individual agendas for a greater appreciation of the complexity of the system. Errors in patient care and failure to achieve desired outcomes are reflective of the enormously complicated systems in which professionals work. Patient safety and quality outcomes are not about individuals or individual disciplines. Quality care reflects a concerted effort to make an interdependent system work well. Getting the right drug to the right patient at the right time reflects a series of interrelated steps involving at least 3 disciplines-nursing, medicine, and pharmacy-and timely communication and delivery mechanisms. A missed dose is not a reflection of inadequate or underprepared nurses. The key to improved quality of healthcare lies in our ability to understand the complex, multidisciplinary, and longitudinal nature of our collective services. Our attention needs to be on the whole as it is woven together in an intricate and sometimes fragile dance.


Relying on an assumption that nursing competency is a major problem of our healthcare today fails to recognize what we have learned from other industries and patient safety experts about the generation of failure and the system's contribution to the problem. System experts have taught us that failure to understand the work of care providers in actual caregiving situations is a major stumbling point in making real progress. 2 Recently published research on the characteristics of nursing work identifies it as highly complex. Much of the complexity is due to the need for nurses to manage highly complicated processes and environmental issues in the midst of delivering individualized care. 3-5 Examples of processes include coordinating a complicated discharge of admission, linking conflicting family and care provider information, managing patient placement to appropriate levels of care, and retrieving critical information for the healthcare team. Environmental issues that add layers of complexity to the nurses' work are missing information, resources, or medications when needed; missing/defective equipment; and a culture lacking effective communication and teamwork. Nursing has only a miniscule understanding about the knowledge and skills needed to survive, much less thrive, in complex systems. Experienced nurses are the repositories of the data, and their experience has just begun to be tapped in initial research aimed at identifying the requisite knowledge and skills for workload management in complex systems. Faculty can teach nursing students the 'picture' of a congestive heart failure patient and the appropriate care guidelines. Staff development instructors can orient the new graduate nurse to the layout of the unit, technology, and location of supplies. What we have failed to appreciate until now is the actual expertise it takes to put it all together in managing an assignment!! Organizing the total assignment for efficiency, reprioritizing across patients and unit needs in the thick of care, and trading off goals across patients and unit needs when everything needs to be done is learned after many months and even years of RN practice. Attaining workload performance proficiency quickly in a complex system is not possible to achieve with nursing's limited understanding of the real nature of our work.


While nursing educators and administrators have used research by Benner and colleagues 6 in education and service settings to understand the unique needs of novices and the importance of clinical case exemplars, we have only begun to scratch the surface about understanding the contributions of expertise to workload management in complex systems. Research conducted by me and my colleagues on expert and novice nurses suggests that expert nurses use the same strategies for decision making for workload management as they do for clinical care. From the start of their shift to finish, expert nurses intuitively match new situations with previous experiences to anticipate and manage workflow. Major factors contributing to their decisions are knowledge of environmental complexities, alternative work-arounds, and the ability to stay ahead of the unpredictable in both patient conditions and environmental factors that arise routinely in the middle of providing care. Expert nurses learn through experience how to manage unpredictability.


Likewise, our research has found that novice nurses exhibit the same narrow focus in managing work as that described by Benner for novices managing specific patient clinical situations. Add the stress of a new or novel situation to their work (new protocol or medication, patient type, or procedure) and a novice nurse becomes a high risk for a near miss or adverse events sometime during the shift. Novice nurses, it appears, do not have the capacity to see pertinent details in the many complicated situations that affect workload management, nor do they possess the experience or confidence that support the best course of action. They are motivated by a desire to provide safe patient care and to demonstrate successful performance in their new role on the unit. Thus, by focusing on patient safety, our research is beginning to identify the exemplary workload management skills of expert nurse regardless of educational preparation-bachelor's, diploma, and associate degree. All nurses appear to need and develop over time knowledge and skills beyond that which is currently offered through prelicensure education or institution-based job orientation.


At their January 14, 2004, board meeting, the American Association of Colleges of Nursing (AACN) passed 8 motions based on the recommendations of the Task Force on Education and Regulation for Professional Nursing Practice 1 and 2 (TFER1 and TFER2). The AACN's board of directors, guided by a desire to 'assure the highest quality nursing workforce for our nation's healthcare needs,' 7 moved forward in their initiative to create a new nurse-clinical nurse leader. A major assumption from the beginning of AACN's work and leading to the board's decisions in January 2004 has been the 'increasing complexity of the healthcare system and growing concerns regarding the quality of patient care (as) evidence of the need for a better educated nursing workforce.' 8 Members of TFER1 cited that an issue driving their discussions was the May 2001 testimony by the Joint Commission on Accreditation of Healthcare Organizations to the United States Senate Committee on Health, Education, Labor, and Pensions that 'nurse competency is a key contributing factor in care delivery problems.'


Adding another nursing role to better accomplish work we don't really understand is a premature answer to a question that is still being formulated. Creating yet another role for nursing follows the path of traditional fixes used in healthcare where erstwhile persons believed that changing a policy, developing a new form, or repeating educational programs would prevent future problems. These strategies did not work-the IOM report stands in testimony to the failure of these strategies. A culture of safety and quality is rooted in understanding and addressing human factors and work complexity.


What would patient care look like with our current pool of nurses working in a healthcare environment designed to decrease or eliminate environmental factors that contribute to safety and quality problems? What if we knew how to teach managing workload and managing unpredictability? In other words, what if nursing collectively responded to the challenge issued in the IOM's report 1 and made significant changes in the healthcare system-design systems that better enable nurses to provide care to patients and reduce the need to 'nursing the system.' Imagine supplies available at the bedside, equipment in working order, information at the touch of a screen in a handheld device, respectful and collaborative communications with all care providers, and goal setting and problem solving that focused on the patient. In this redesigned healthcare system, the level of nursing care would be clear, and the patient needs would be matched with the skills of the nurse provider. Perhaps then we would be able to address the educational needs of the nursing workforce and move forward together to make sure that every patient receives the level of nursing care expertise needed to reach quality outcomes and to assure that novice nurses learn from experts how to manage workload in a complex system.


The issues cited by AACN as rationale for a new nurse are important. However, confronted with what we don't know about the complexity of nurse work, I am concerned that the new nurse is an old strategy. Clinical nurse specialist (CNS) practice includes a system level focus and CNSs appreciate nurse work in complex systems. The challenge is ours, CNSs, to help move the agenda toward improved understanding of and increased focus on the complexity of our work for the purpose of having a vision for tomorrow's healthcare system. CNSs are up to the task, leading real change that benefits patients and those nurses who do their best to provide care every day.




1. IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. [Context Link]


2. Cook R, Render M, Woods D. Gaps in the continuity of care and progress on patient safety. Br Med J. 2000;320:791-794. [Context Link]


3. Ebright PR, Patterson ES, Chalko BA, Render ML. Understanding the complexity of registered nurse work in acute care settings. J Nurs Adm. 2003;33:630-638. [Context Link]


4. IOM (Institute of Medicine). Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press; 2004. [Context Link]


5. Potter P, Boxerman S, Wolf L, et al. Mapping the nursing process: a new approach for understanding the work of nursing. J Nurs Adm. 2004;34:101-109. [Context Link]


6. Benner P, Tanner C, Chesla C. Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. New York: Springer; 1996. [Context Link]


7. Talking Points: AACN board decisions regarding the clinical nurse leader initiative. Available at: Accessed May 18, 2004. [Context Link]


8. Report of the Task Force on Education and Regulation for Professional Nursing Practice 1. Available at: Accessed May 18, 2004. [Context Link]